The Opiate Cure: Pain and the Bipolar Spectrum

By Robert T. Cochran and Robert T. Cochran Jr. MD

THE OPIATE CURE tells the stories of painful people whose
mental illness were relieved when they were given opiates for
their pain. This improbable outcome has occurred in those with
bipolar depression and mania, attention defi cit disorder, obsessivecompulsive disorder, and narcolepsy. These several diseases are now linked together, constituting the bipolar spectrum. Linked also to bipolar spectrum is chronic pain in its many forms, including migraine. This book will clearly demonstrate that bipolar spectrum is uniquely responsive to opiate therapy. The Opiate Cure offers new insights and, more importantly, hope.

• Language: English
• Publisher: Xlibris US
• Release date: Dec 9, 2011
• ISBN: 9781465391506

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Copyright © 2011 by Robert T. Cochran Jr., MD.

Library of Congress Control Number:       2011960148

ISBN:         Hardcover                               978-1-4653-9149-0

                   Softcover                                 978-1-4653-9148-3

                   Ebook                                      978-1-4653-9150-6

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CONTENTS

Preface

Introduction

Chapter 1 Drugs for Pain and the Bipolar Spectrum

Chapter 2 The Bipolar Way

Chapter 3 Cure and Denial

Chapter 4 Cure and Stigma

Chapter 5 The Spectrum

Chapter 6 Dreams

Chapter 7 Flashbacks

Chapter 8 Attention Deficiency

Chapter 9 Obsessions

Chapter 10 Multiple Personalities

Chapter 11 Cutting and Biting

Chapter 12 Voiding

Chapter 13 Craving

Chapter 14 Blaming

Chapter 15 Concluding

To those who suffer from chronic pain and bipolar disorder

and the stigma of taking a drug that cures

PREFACE

About four years ago, I had both knees replaced. The operation and my convalescence were uncomplicated except for an issue that distressed me greatly. I couldn’t sleep. Each night, my mind was overwhelmed with memories of pleasurable experiences—biking, skiing, backpacking, and fishing with friends and family. I quickly grew tired of remembering the happy times. I wanted desperately to be able to sleep, but I could not. My mind was too busy, and for the only time in my life, a force beyond my control was commanding my thoughts. Only after several days at home was I able to think as I wished as I awaited sleep. What had happened to me? I want to suggest to you that I experienced just a touch of bipolar mania. The appearance of mania after a surgical operation is by no means unheard of. And characteristics of mania are sleeplessness, mind busyness, and sometimes obsessive and repetitive thought. Bipolar mania makes us think what we don’t want to think, and that is what happened to me. I do not, by any conventional standard of measure, suffer from bipolar disorder; but I want to suggest to you that maybe all of us, at some time or another in our lives, become a little bit bipolar, especially when we are in pain. Keep that in mind as you read this book.

I am indebted to many people for their assistance in preparing this work. Donna, my wife of many years, has once again given me time and space to write about something that I think is quite important. I have been supported greatly during the time of this writing by my office staff. Their names are Jan Diehl, Janet Epstein, Linda Harris, Pat Alley, Renee Turman, Tammy Gohlson, and B. J. Tucker. I have also been supported by my transcriptionist, Sherry Jolly, who does the important little things for me, like spelling and punctuating. I am indebted to the many physicians who have referred their difficult patients to me. As you will see in this book, my referrals come from across the spectrum of medical specialists—all the way from psychiatrists to urologists. Thus, it has been my privilege to see people with a remarkable variety of painful disorders. Lastly, I express my gratitude to my patients who have taught me so much. I hope this book will express my devotion and the respect I hold for them. It is their stories that I offer you in the certain knowledge that as you read of others, you will find yourself and will be comforted by the fact that you are not alone, that there is hope for recovery, and that you need not be ashamed of taking pain pills.

INTRODUCTION

For those of you unfamiliar with my writings on the subject of chronic pain, I will briefly summarize them and in doing so introduce you to this work.

In 2004, I published my first book, Understanding Chronic Pain. I accepted the generally held belief that chronic pain could best be defined as pain that extends beyond the anticipated time of recovery from illness or injury. I pointed out, however, that when this happens, there appears, almost invariably, a host of other symptoms in addition to the pain. These include disordered sleep, appetite, energy, mood, thought, memory, and even motor skills. I emphasized that these symptoms coexist so frequently with chronic pain that they must be considered inherent to the disease; and it matters not whether the painful state is fibromyalgia, headache, back pain, neuritis, arthritis, or whatever. Clearly, there is great commonality among those who suffer from chronic pain. For this reason and others, I suggested that although chronic pain may appear in a variety of forms, it represents a single core illness. I suggested also that the illness could be best considered a disorder of the mind. The reasons for this are several. Chronic pain is often preceded by the psychiatric disorders of substance abuse and depression and also very commonly by childhood trauma—particularly sexual abuse, which, as you may know, is the mother of many psychiatric diseases. Moreover, chronic pain often coexists with a psychiatric illness, including depression, panic, bipolar disorder, attention deficit disorder, post-traumatic stress disorder, obsessive-compulsive disorder, multiple personality disorder, and others. In my book, I presented the case histories of people with chronic pain who were successfully treated by the introduction of psychopharmacy (drugs for the mind). I concluded that recognition and treatment of the coexistent (comorbid is the medical term) psychiatric disease could often relieve pain.

My book did well, and 2006 found me working on a second edition. Mainly, I was pleased with my work. My ideas seemed to be standing the test of time, at least as measured over a couple of years. Therefore, I made no major revisions in the new edition. Nonetheless, a couple of lines of thought were evolving: one related to the role of opiate therapy and the other to bipolar disorder. Let’s take bipolar first.

I had written about a man whose recurrent back pain went away when his bipolar disease was treated with Lithium. Thus, I did appreciate a link between the two diseases, but I thought the effect was probably quite rare because (I believed then) the incidence of bipolarity in the population at large was only about 2 or 3 percent. However, as time went by and I learned more about bipolar disorder, I began to recognize the very great frequency of bipolarity in my patients with chronic pain. Moreover, I found myself becoming more comfortable and confident in treating people who suffer from both pain and bipolarity. The reader is advised that that can be an intimidating combination. The victims of bipolar disorder are brittle emotionally, behaviorally, and also pharmacologically. Their responses to drug therapy are often adverse and unpredictable. Drugs that should make them better can make them worse. Moreover, there is a high incidence of drug abuse in the bipolar population. (Some 50 percent of heroin addicts are bipolar!)

It was in the summer of 2006 that I first learned of the emerging concept of the bipolar spectrum. Psychiatrists were recognizing that bipolar disorder was often linked—that is to say, comorbid—with narcolepsy, migraine, attention deficit disorder (ADD), and obsessive-compulsive disorder (OCD). There was also increasing awareness that bipolarity and chronic pain in their many forms were often comorbid. I bought into the concept quickly because it fit with so many of my own ideas, but I did strike out a couple of times. I should have appreciated a link between bipolarity and migraine because I was seeing plenty of both, but I didn’t make the connection. In but a short while, however, I realized that migraine is quite common in the bipolar, and it is often severe and treatment resistant. The link to narcolepsy had escaped me entirely, but I did recall that some of my patients did complain of vivid threatening dreams, a hallmark of narcolepsy.

I was sure the concept of the bipolar spectrum was correct. I accepted unreservedly the clinical link—that is, the simultaneous existence of some or all of these disorders in one person. And I knew also that there was very likely a genetic link. Bipolarity is often a familial disease, and many of my bipolars in pain had children with ADD. Now could there be a therapeutic link? That is, could the treatment of one disorder in the spectrum relieve the others? Particularly, what would be the role of psychostimulant (Ritalin is an example) therapy? The psychostimulants are indicated in the treatment of both attention deficit disorder and narcolepsy. What would be their place in the treatment of bipolar disorder, chronic pain in general, and migraine in particular? I knew I would find out pretty soon.

My opportunity came when a woman with arthritic knee pain was referred to me. She was bipolar and had spent years on treatment with many drugs. She told me that as her pain had appeared and was progressively worsening, she had developed a problem with mood shifts (bipolarity), forgetfulness, want of mental focus, and distractibility (ADD). In response to my questioning, she reported that she had throughout her life been subject to vivid dreams. Moreover, she was fatigued and sleepy in the daytime (narcolepsy). I felt I had limited treatment choices. I certainly wasn’t going to employ conventional psychopharmacy because she had already been on most of the drugs I use, and many of them had made her worse. That left opiates for her pain or stimulants for her attention deficiency and narcolepsy. Fearful (at that time) of opiates in the bipolar, I prescribed Ritalin knowing that it might precipitate mania. But I also knew that any drug I chose might precipitate mania. It wasn’t a very attractive choice, but I thought it was the best. The only other option was to tell her I had nothing to offer, and I don’t like doing that. Her recovery was sudden and total. Within but days, her pain was relieved, her distractibility diminished, her energy restored, her sleepiness overcome, and, in short order, her nightmares went away. Astonishingly also, her mood shifts were arrested.

Encouraged, to say the least, by her response, I continued to pursue the role of psychostimulant therapy. I encountered a young woman with accelerating migraine and also anxiety and, with them, the appearance of nightmares. Again, the improvement with stimulant therapy was dramatic. Her migraines disappeared, and her anxiety level was diminished. I was also to discover later that her dental phobia was totally abated. She could attend, under the sponsorship of my therapy with Ritalin, a dental appointment without fear or anxiety. Next I encountered a patient with migraine who also suffered from obsessive-compulsive disorder, which was only partially responsive to treatment. She reported very threatening dreams. I introduced stimulant therapy, and not only were her migraines and dreams diminished, but her obsessive-compulsive disorder also.

It had not taken long to validate, at least in my mind, the concept of the bipolar spectrum. It made bipolarity bigger and more complex than I had thought, but also more vulnerable. There were more points of attack.

Now back to opiates. In Understanding Chronic Pain, I had largely neglected, perhaps even disparaged, the use of opiates. I worried (probably too much) about addiction. A bigger issue was that the opiates, I thought then, were rather ineffective in the treatment of chronic pain. Such was my enthusiasm for the role of psychopharmacy that I wrote that the victim of chronic pain can actually get well or nearly so with those drugs. The victim of chronic pain did not get well with opiates, only a bit better until it was time for another pill. Nonetheless, one cannot be a pain doctor and not use opiates, and as time was going by, I was becoming more knowledgeable about the opiates and more aggressive in their use. Whereas formerly I had chosen to employ the weakest—and presumably least addictive—opiates, I had, with increasing experience, begun to employ stronger ones in bigger doses and often in combination. I finally realized that the generous prescription of opiates can reduce human suffering; and that, I concluded, should include bipolar human suffering.

A man who had endured multiple spinal operations and had chronic back pain was referred to me. He had become extremely obese, for chronic pain is often a food-craving, weight-gaining disease. With his pain, he had evolved, as is so often the case, into unstable bipolarity with depression, suicidal ideation, and periods of manic hyperactivity and anger requiring hospitalizations and, on one occasion, incarceration. He was under psychiatric care, receiving multiple drugs without much success. I was not attracted to giving him more, so I elected to simply prescribe morphine for his pain. Within days, his pain was relieved, and his mood was stabilized in a manner he had not known for years on conventional therapy. Moreover, his lust for sweets was abated, and he started losing weight rapidly.

Next a woman in her forties who had been raped and shot in the neck by her ex-husband. The carotid artery was damaged but surgically repaired without incident. The bullet, however, remained lodged in the vertebral column, and surgery to remove it would carry a high risk of paralysis. Her neck remained painful, and she required the use of a thick collar to prevent painful neck movement. Within a few months of her assault, she developed post-traumatic stress disorder with anxiety, depression, and terrifying flashbacks of the event. She attempted suicide and required hospital admission. While there, her mood-shifting bipolar disorder was recognized and treated. However, in spite of aggressive psychiatric care with many medications, she remained anxious, angry, painful, and mood unstable. I prescribed Morphine. On her return, she reported that she didn’t hurt quite as badly, but that little else had changed. I probably should have increased the dose of Morphine. It was helping a bit, and she was having no significant side effects; but for reasons still uncertain to me, I elected to add another opiate, Methadone. On her return, she was unencumbered by the collar. She moved about gracefully, and she told me with a radiant smile that I had cured her. The pain was gone; and so were her anxiety, depression, and mood shifts. Moreover, she was no longer having flashbacks.

I had, within the course of but a month, seen two unstable bipolars whose disease was totally and suddenly arrested by the administration of opiates. Both of them were clinical miracles, and one does occasionally see a random clinical miracle. But two nearly identical miracles in one month are not random. I did some research and discovered that in the first half of the twentieth century, before the advent of our contemporary pharmacy for psychiatric disease, Morphine was sometimes used for the treatment of depression, mania, and delirium. Occasionally, it worked. The effect was called the opiate cure.

Once again the bipolar spectrum was validated. Just think about it. By employing a stimulant in persons with narcolepsy or attention deficiency and employing an opiate in persons with chronic pain, I had not only relieved the pain of arthritis, migraine, a multiply-operated low back, and a bullet in the neck, I had also cured or ameliorated bipolar disorder, obsessive-compulsive disorder, attention deficit disorder, phobia, post-traumatic stress disorder, narcolepsy, and even obesity! It beggars the imagination that all this could happen in only five patients. But it is true.

I knew I had to share these stories, and I began my second book, to be entitled Curing Chronic Pain. To a remarkable extent, I was learning as I was writing. So rapidly coming were new experiences and new ideas that at least a third of the material presented in the book, I did not know when I began writing it. Indeed, I found it difficult to end the book because almost daily, it seemed, there was a new experience and a new insight. Fortunately for me, the learning curve, which had been ascending at great velocity over the course of a couple of years, has slowed a bit; and that is good. It has given me time to gather my thoughts and process what I have learned. It has also given me time also to increase my database. My population of patients with chronic pain and the bipolar spectrum on treatment with opiates or stimulants (and sometimes both) has grown from a few dozen to several hundred. I have come to embrace the concept of the bipolar spectrum and, more importantly, its clinical application. By understanding the scope of the disease and its very common association with chronic pain, I am better able to treat both.

The acceptance of my ideas by those whom I have treated for chronic pain and bipolarity, usually quite successfully, has been enthusiastic. Others who have read my books or visited my Web site have also been accepting, and I will shortly share some of their e-mails with you. Among the medical community, however, acceptance has been much more hesitant. There are, I believe, many reasons for this—some good and some not so. One is the sheer improbability that stimulants, and especially opiates, can relieve such a host of different psychiatric disorders, even those that were resistant to conventional therapy, so quickly and so totally. It is too good to be true, and therefore, it challenges credulity. Moreover, if it is indeed true, why had we not recognized it sooner? The opiates have been around for millennia, stimulants for over a century. If their effects are as dramatic as I have written, why did we not see it? Actually, we had. The use of opiates for the treatment of mental illness was widely practiced throughout the Western world, perhaps most so in Germany, but certainly also in the United States. I will remind the reader that the only other treatment for severe mental illness in the opiate era was the prefrontal lobotomy, the surgical destruction of a portion of a person’s brain. With the development of electroconvulsive therapy in the 1930s, and then effective psychopharmacy in the 1960s, both the opiate cure and the prefrontal lobotomy were consigned to oblivion. The prefrontal lobotomy fortunately so. The opiate cure—well, one wonders.

A bigger issue relating to the acceptance of opiate therapy for psychiatric disorders lies in our medical and societal attitudes toward the drugs. All agree that they are necessary for the relief of acute pain, and nearly all agree that they should also be employed in the long-term treatment of chronic pain. Nearly all also agree, the author and a few others excepted, that they have no other real clinical utility beyond the relief of pain. Moreover, they are dangerous to the person who uses them regularly because he will become addicted and to the doctor who prescribes them because he will lose his license. The extent of this fear cannot be overstated, and that is why so few doctors use opiates generously and therefore why so few doctors have the opportunity to witness the opiate cure.

I was for twenty years a pain doctor, prescribing opiates regularly, before I witnessed it. It was an exercise in serendipity (finding something good that you are not looking for). It was a chance discovery; but it was also, I believe, providential. It came at a time in my career when I had recognized the frequency of bipolarity in my patients in pain, when I had discovered the enormity of the bipolar spectrum, and when I was learning to administer opiates aggressively. The two unstable bipolars who experienced the opiate cure were not merely case studies. They were a message that there was a link between the bipolar spectrum, chronic pain, and perhaps uniquely to those disorders, opiate therapy. My patients got better because they were bipolar, and they probably also had pain because they were bipolar. Curious, and perhaps ironic, that the opiates—drugs that I had disparaged in print but four years before—were suddenly becoming my bedrock for the treatment of the bipolar in pain; and there are an awful lot of those out there.

CHAPTER 1

Drugs for Pain and the Bipolar Spectrum

I have elected, as in my previous books, to list in tabular form the drugs that will be referenced in this text. Many of my readers, most of whom have taken several of these drugs, tell me that this kind of overview at the beginning of the book is helpful.

Be advised that drugs of great variety are employed in the treatment of bipolarity and pain. Some of them have been approved by the Federal Drug Administration (FDA) for those purposes, but some have not. The latter usage derives from the not infrequent discovery that a new drug, indicated for the treatment of a specific symptom or disease, is often found to be effective in treating other symptoms and diseases. Thus, the prescription of drugs for non-FDA approved purposes, known as off-label prescribing, is widely recognized as appropriate and needful.

Most of the drugs discussed in this book influence the way nerve cells (neurons) within the brain communicate with each other. A chemical, the neurotransmitter, is released from one cell and attaches to a site, known as a receptor, on the surface of another cell. Virtually all of the brain’s functions perform under the persuasion of neurotransmitters and their receptors. It is their dysfunction that is the cause of most neuropsychiatric illness; and it is correction of that dysfunction with pharmacy that allows us to relieve, or at least control, mental illness.

I discussed, at some length, neurotransmitters and their function in Curing Chronic Pain. I will not repeat that exercise, in part because I believe once is enough and in part also because this is really not my area of expertise. In this chapter, I will speak only briefly on the matter but will in text elaborate on it when it is appropriate.

Antidepressants

Selective Serotonin Reuptake Inhibitors (SSRI)

The SSRIs are the best known of the antidepressants. They enhance the activity of the nerve transmitter serotonin, which is the brain’s own antidepressant. They also have antianxiety properties and have to a large measure supplanted the more conventional anxiolytics (tranquilizers) in the treatment of anxiety. Unfortunately, perhaps because of their selective serotonin activity, they are only modestly effective as analgesic (pain-relieving) drugs. They can be very effective in the bipolar although occasionally untoward reactions, particularly mania, can be generated by the SSRIs.

Tricyclic and Tricyclic-like Antidepressants

These, the first widely used antidepressants clearly have pain-relieving attributes. This is because they increase not only the activity of serotonin but also noradrenaline, which is one of the brain’s own pain-controlling nerve transmitters. They, perhaps more than any other class of drugs, carry the risk of the induction of mania in the bipolar. Nonetheless, they can be extremely helpful in victims of that disorder. More recently there have appeared tricyclic-like drugs, which are also effective for pain and bipolar depression. They are Effexor and Cymbalta. A kindred drug, known as Savella, has only recently been released. It appears to enhance only the activity of noradrenaline and has been FDA-approved for the treatment of the pain of fibromyalgia.

Dopamine Antidepressants

Dopamine, the brain’s gratification, reward, and pleasure neurotransmitter is enhanced by dopamine antidepressants. A very similar effect is achieved by the psychostimulants, which will be addressed shortly.

Anxiolytics

This group of drugs, also known as tranquilizers, belongs to a chemical class known as benzodiazepine. They enhance the activity of gamma-aminobutyric acid (GABA), which is the brain’s calming and sedating neurotransmitter. Their use is disdained by many because of their potential for addiction. Nonetheless, they can be extremely helpful drugs in the treatment of pain. Those asterisked below particularly so, perhaps because of their anticonvulsant (antiepileptic) properties.

Anticonvulsants

There are a great number of these drugs, and they all were released with the original indication for the treatment of epilepsy. All, virtually without exception, are useful also for the prevention of migraine and for the control of bipolar mood swings. They do not act on a specific neurotransmitter but, rather, render the nerve cell membrane, that which carries electrochemical message throughout the length of the cell, less volatile and irritable. It is this nerve cell irritability that is probably the root cause of epilepsy, migraine, mania, and perhaps also chronic pain, and the anticonvulsants are widely used for those disorders. Only one of the drugs listed below has no anticonvulsant activity, but it was historically the first drug (if we exclude the opiates) for the treatment of bipolar mania. It is Lithium.

Antipsychotics

This group of drugs was originally designed for the treatment of schizophrenia. They also are useful for the treatment of agitation and delirium, particularly in the elderly with dementia. They appeared early on to have fewer of the troublesome side effects that accompanied the first antipsychotics (of which Thorazine, Prolixin, and Haldol will be referenced in this book). They were also discovered to be quite helpful in the treatment of bipolar disorder, and they are widely employed for that purpose. In recent years, however, there has come increasing awareness of the side effects of obesity and diabetes.

Psychostimulants

These drugs, most derived from amphetamine, are widely used in the treatment of attention deficit disorder, narcolepsy, fatigue, daytime sleepiness, and occasionally, depression. They can be, as we have already seen, mood-stabilizing, anxiolytic, and migraine-preventing in the bipolar. Most of them enhance the activity of the neurotransmitter, dopamine (as does cocaine), and perhaps for this reason they carry the capacity for addiction. However, they also stimulate noradrenaline, and that may account for their occasional pain-relieving effects. Two of the psychostimulants are neither amphetamine-derived nor dopamine enhancers. Rather, they stimulate noradrenaline. They are widely used for the treatment of attention deficit disorder (Strattera) and excessive sleepiness (Provigil), but, curiously, their analgesic effect appears to be limited.

*Extended Release Preparations

Antimigraine Drugs

These agents are collectively identified from a common chemical structure as triptan. They influence the activity of serotonin in blood vessels and not in the brain. They cause vascular constriction, and that opposes the pain-inducing vascular dilatation that is the hallmark of migraine. They will be referenced several times in this text.

Opioid Analgesics

Most of the pain-relieving opioids are derivative of the opium poppy (papaver somniferum) although some are prepared synthetically. They enhance the effect of the endorphins, the brain’s own pain-relieving neurotransmitter. They are predictably effective in the treatment of the acute painful illness or injury but less so in those who suffer from chronic pain. The exception, as I will demonstrate throughout this book, is in those who suffer from pain and bipolar disorder. In that group of people, they can be not only pain-relieving, but also anxiety-diminishing, mood-stabilizing, depression-alleviating, attention-restoring, obsession-diminishing, and migraine-preventing. They are certainly the most addictive of the drugs referenced in this book, and their abuse is an enormous medical and societal problem. Nonetheless, I believe in the appropriate circumstance, and these are not few, their benefit can be remarkable. I am hopeful that the coming decades will witness the birth of the science of opiate psychopharmacology, the study of why and how opiates can be so helpful for mental illness, particularly for the bipolar spectrum and its many and varied expressions.

Two of the opiates, Buphrenorphine and Methadone, possess the capacity to inhibit withdrawal from heroin and other opiates and also to diminish cravings for those drugs. They are widely employed in the detoxification from opiates.

* Extended release preparation

Some of these drugs are formulated in combination with